Control, struggle, and emergent masculinities: a qualitative study of men's care-seeking determinants for chronic cough and tuberculosis symptoms in Blantyre, Malawi.

BACKGROUND: Men's healthcare-seeking delay results in higher mortality while on HIV or tuberculosis (TB) treatment, and implies contribution to ongoing community-level TB transmission before initiating treatment. We investigated masculinity's role in healthcare-seeking delay for men with TB-suggestive symptoms, with a view to developing potential interventions for men. METHODS: Data were collected during March 2011- March 2012 in three high-density suburbs in urban Blantyre. Ten focus group discussions were carried out of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers. Individual interviews were done with 20 TB patients (female =14) and 20 un-investigated chronic coughers (female = eight), and a three-day workshop was held with 27 health stakeholder representatives. RESULTS: An expectation to provide for and lead their families, and to control various aspects of their lives while facing limited employment opportunities and small incomes leaves men feeling inadequate, devoid of control, and anxious about being marginalised as men. Men were fearful about being looked at as less than men, and about their wives engaging in extramarital sex without ability to detect or monitor them. Control was a key defining feature of adequate manhood, and efforts to achieve it also led men into side-lining their health. Articulate and consistent concepts of men's bodily strength or appropriate illness responses were absent from the accounts. CONCLUSIONS: Facilitating men to seek care early is an urgent public health imperative, given the contexts of high HIV/AIDS prevalence but increasingly available treatment, and the role of care-seeking delay in TB transmission. Men's struggles trying to achieve ideal images seem to influence their engagement with their health. Ambiguous views regarding some key masculinity representations and the embrace of less harmful masculinities raise questions about some common assumptions that guide work with men. Apparent 'emergent masculinities' might be a useful platform from which to support the transformation of harmful masculinity. Finally, the complex manifestations of masculinity indicate the need for interventions targeting men in health and TB control to assume supportive, multidimensional and long-term outlooks

Artificial Immunology for Collective Adaptive Systems Design and Implementation

Distributed autonomous systems consisting of large numbers of components with no central control point need to be able to dynamically adapt their control mechanisms to deal with an unpredictable and changing environment. Existing frameworks for engineering self-adaptive systems fail to account for the need to incorporate self-expression—that is, the capability of a system to dynamically adapt its coordination pattern during runtime. Although the benefits of incorporating self-expression are well known, currently there is no principled means of enabling this during system design. We propose a conceptual framework for principled design of systems that exhibit self-expression, based on inspiration from the natural immune system. The framework is described as a set of design principles and customizable algorithms and then is instantiated in three case studies, including two from robotics and one from artificial chemistry. We show that it enables self-expression in each case, resulting in systems that are able to adapt their choice of coordination pattern during runtime to optimize functional and nonfunctional goals, as well as to discover novel patterns and architectures

Operationalising generalism in medical education: a narrative review of international policy and mission documents

Introduction Despite moves across medical education to increase learning of generalist principles, a lack of clarity about what generalism means and how we should train doctors as ‘generalists’, has remained. This study explores how international, undergraduate and postgraduate, policy and educational mission documents characterise the practice and learning of generalism and how this can inform physician training. Methods A narrative literature review was conducted based on policy and mission documents identified through grey literature searches and a wider systematic review looking at empirical texts. Texts published between 1999 and present and related to ‘generalism’ were eligible for inclusion. Texts were coded and codes were reviewed and grouped into key themes. Results Thirty-four documents were included. Definitions vary: some described generalism as a basic skill, whilst others emphasised expertise. Factors which support learning generalism include: favourable financial outcomes; ageing populations; coordination of multidisciplinary care; demand for doctors with transferable skills; and patient expectations. Barriers to learning about generalism include: preference for specialisation; structure of undergraduate teaching and assessment; and the hidden curriculum. Solutions may include re-imagining generalists and specialists as being on a continuum as well as increasing exposure throughout medical education. Discussion Whilst generalism is consistently positioned as valuable, less clarity exists about how best to operationalise this in medical education. Fundamental ideological and structural changes within teaching curricula and assessment, are necessary to improve generalist learning and to promote sustainable practice. Medical education needs careful, considered planning to ensure workforce expertise is meeting population needs

The Reasons for Discontinuation of Infliximab Treatment in Patients with Crohn's Disease: A Review of Practice at NHS Teaching Hospital

Introduction. There is little information on the reasons for discontinuing infliximab treatment in patients with Crohn's disease. The aim of this study was to document these reasons to determine if any were preventable which would allow patients to continue the therapy. Aims & Methods. A review of the medical notes was conducted at the Norfolk and Norwich University Hospital on patients with Crohn's disease treated with infliximab between 2002–2008 to determine the reasons for stopping it. Results. A total of 65 patients were identified who had treatment with infliximab, of whom 23 (35.3%) had their therapy stopped. The reasons for discontinuation of infliximab in the 23 patients were: 47.8% side effects, 17.4% refractory disease, 13.0% achieved remission and did not receive long-term maintenance treatment, 4.34% pregnancy, 4.34% death, and unknown 13.0%. Conclusions. The main reasons for the discontinuation of infliximab were side effects rather than a lack of clinical response

Multidimensional collaboration; reflections on action research in a clinical context

This paper reflects on the challenges and benefits of multidimensional collaboration in an action research study to evaluate and improve preoperative education for patients awaiting colorectal surgery. Three cycles of planning, acting,observing and reflecting were designed to evaluate practice and implement change in this interactive setting, calling for specific and distinct collaborations. Data collection includes: observing educational interactions; administering patient evaluation questionnaires; interviewing healthcare staff, patients and carers; patient and carer focus groups; and examining written and audiovisual educational materials. The study revolves around and depends on multi-dimensional collaborations. Reflecting on these collaborations highlights the diversity of perspectives held by all those engaged in the study and enhances the action research lessons. Successfully maintaining the collaborations recognises the need for negotiation, inclusivity, comprehension, brokerage,and problem-solving. Managing the potential tensions is crucial to the successful implementation of changes introduced to practice and thus has important implications for patients’ well-being. This paper describes the experiences from an action research project involving new and specific collaborations, focusing on a particular healthcare setting. It exemplifies the challenges of the collaborative action research process and examines how both researchers and practitioners might reflect on the translation of theory into educational practices within a hospital colorectal department. Despite its context-specific features, the reflections on the types of challenges faced and lessons learned provide implications for action researchers in diverse healthcare settings across the world

The evaluation of Carousel : a therapeutic programme for prisoners who self-harm

Prison self-injury rate accelerates at four times the rise in population” (The Howard League for Penal Reform; 2008a) The rise in self-harm figures in forensic settings in 2003 may largely be due to the improvement in the reporting of self-harm levels in prisons in December 2002. However it does not account for the continued rise in self-harm figures during the years that followed. Despite the increase, there have been few interventions to support prisoners who self-harm, particularly in remand settings. For this purpose the Carousel programme was designed by a counselling psychologist specifically to meet the demands of the female remand population. The aim of this study was to evaluate the effectiveness of Carousel. Forty women who had a history of deliberate self-harm entered and completed the programme through means of self-referral. The study employed both a quantitative and qualitative methodology to evaluate the programme. Participants were interviewed and assessed both at the start and completion of Carousel. This included monitoring levels of self-harm incidents, levels of anxiety and depression using the 14-item Hospital Anxiety and Depression Scale (HADS) (Zigmond ;Snaith, 1983), and coping levels using the 60-item Coping Styles Questionnaire (CSQ) (Roger, Jarvis ;Najarian, 1993). Results showed a significant decrease in depression and anxiety, a reduction in self-harm levels and a change of coping styles in the desired direction. Qualitative methodology using content analysis was employed to ascertain the components of the programme which were deemed most helpful or unhelpful to the participants. Findings suggest that the most useful components within the programme are coping strategies, management of self-harm behaviours, antecedent, behaviour and consequence (ABC) sessions and the understanding of the brain and associated emotions with self-harm behaviours. Implications for counselling psychology and clinical practice are highlighted and limitations of the current study and directions for future research suggested within the report.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Effect of Experimental Change in Children’s Sleep Duration on Television Viewing and Physical Activity

Background Paediatric observational studies demonstrate associations between sleep, television viewing and potential changes in daytime activity levels. Objective(s) To determine whether experimental changes in sleep lead to changes in children's sedentary and physical activities. Methods Using a within-subject counterbalanced design, 37 children 8–11 years old completed a 3-week study. Children slept their typical amount during a baseline week and were then randomized to increase or decrease mean time in bed by 1.5 h/night for 1 week; the alternate schedule was completed the final week. Children wore actigraphs on their non-dominant wrist and completed 3-d physical activity recalls each week. Results Children reported watching more television (p < 0.001) and demonstrated lower daytime actigraph-measured activity counts per epoch (p = 0.03) when sleep was decreased (compared with increased). However, total actigraph-measured activity counts accrued throughout the entire waking period were higher when sleep was decreased (and children were awake for longer) than when it was increased (p < 0.001). Conclusion(s) Short sleep during childhood may lead to increased television viewing and decreased mean activity levels. Although additional time awake may help to counteract negative effects of short sleep, increases in reported sedentary activities could contribute to weight gain over time

Treatment-seeking for tuberculosis-suggestive symptoms: a reflection on the role of human agency in the context of universal health coverage in Malawi

Tuberculosis (TB) is highly infectious and one of the leading killers globally. Several studies from sub-Saharan Africa highlight health systems challenges that affect ability to cope with existing disease burden, including TB, although most of these employ survey-type approaches. Consequently, few address community or patient perspectives and experiences. At the same time, understanding of the mechanisms by which the health systems challenges translate into seeking or avoidance of formal health care remains limited. This paper applies the notion of human agency to examine the ways people who have symptoms suggestive of TB respond to and deal with the symptoms vis-à-vis major challenges inherent within health delivery systems. Empirical data were drawn from a qualitative study exploring the ways in which notions of masculinity affect engagement with care, including men's well-documented tendency to delay in seeking care for TB symptoms. The study was carried out in three high-density locales of urban Blantyre, Malawi. Data were collected in March 2011 -March 2012 using focus group discussions, of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers; and in-depth interviews with 20 TB patients (female = 14) and 20 un-investigated chronic coughers (female = eight). The research process employed a modified version of grounded theory. Data were coded using a coding scheme that was initially generated from the study aims and subsequently progressively amended to incorporate concepts emerging during the analysis. Coded data were retrieved, re-read, and broken down and reconnected iteratively to generate themes. A myriad of problems were described for health systems at the primary health care level, centring largely on shortages of resources (human, equipment, and drugs) and unprofessional conduct by health care providers. Participants consistently pointed out how the problems could drive patients from promptly reporting symptoms at primary healthcare centres. The accounts suggest that in responding to illness symptoms including those suggestive of TB, patients navigate their options taking into cognisance past and current experiences with formal health systems. Understanding and factoring in the mediating role of such 'agency' is critical when implementing efforts to promote timely response to TB-suggestive symptoms

Childhood and the politics of scale: Descaling children's geographies?

This is the post-print version of the final published paper that is available from the link below. Copyright @ 2008 SAGE Publications.The past decade has witnessed a resurgence of interest in the geographies of children's lives, and particularly in engaging the voices and activities of young people in geographical research. Much of this growing body of scholarship is characterized by a very parochial locus of interest — the neighbourhood, playground, shopping mall or journey to school. In this paper I explore some of the roots of children's geographies' preoccupation with the micro-scale and argue that it limits the relevance of research, both politically and to other areas of geography. In order to widen the scope of children's geographies, some scholars have engaged with developments in the theorization of scale. I present these arguments but also point to their limitations. As an alternative, I propose that the notion of a flat ontology might help overcome some difficulties around scalar thinking, and provide a useful means of conceptualizing sociospatiality in material and non-hierarchical terms. Bringing together flat ontology and work in children's geographies on embodied subjectivity, I argue that it is important to examine the nature and limits of children's spaces of perception and action. While these spaces are not simply `local', they seldom afford children opportunities to comment on, or intervene in, the events, processes and decisions that shape their own lives. The implications for the substance and method of children's geographies and for geographical work on scale are considered